Dear Doctors: I have been told I have a stage 2 rectocele and that there are two ways to approach treating it. One is insertion of something into the rectum; the other is surgery. Can you please discuss these two options? Could doing physical therapy be helpful?
Dear Reader: The term rectocele refers to a type of pelvic organ prolapse. It can occur when the wall of supportive tissue that sits between the rectum and the vagina, known as the rectovaginal septum, becomes weakened. Both the rectum and the vagina are flexible passageways that rely on surrounding tissues to help maintain their hollow structure. If that support weakens, it becomes possible for the tissues of the rectum to begin to push against the rear wall of the vagina. When this results in a bulge that intrudes into the passageway of the vagina, it is known as a rectocele.
The vast majority of cases are seen in women.
Risk factors for developing a rectocele include multiple vaginal deliveries; stress, trauma or damage to the vaginal tissues, including during a vaginal delivery; chronic constipation, which can lead to repeated straining during bowel movements; gynecological or rectal surgeries; and the physical changes that occur after menopause.
Symptoms include a feeling of fullness within the vagina, rectal pain or bleeding, and an increase in difficulty in emptying the rectum during a bowel movement. Additional effects can include itching that may become intense, fecal incontinence and sexual dysfunction.
The degree of protrusion in a rectocele can range from so slight as to be undetectable to pronounced enough that the tissues of the rectum can be felt or seen within the vagina. In stage 2 rectocele, herniated tissue may be visible within the vagina.
Treatment depends on the degree of prolapse and the individual’s age and physical condition. When the condition is mild, nonsurgical management is recommended. A high-fiber diet, along with fiber supplements, stool softeners and adequate hydration will help ease bowel movements and lessen straining. Post-menopausal women may benefit from hormone replacement therapy. Pelvic floor exercises have also been found to be quite effective.
In more advanced cases of rectocele, surgery may be required. This entails removing the herniated tissue and using sutures to reinforce the supportive wall of tissue between the vagina and the rectum. The procedure is performed either by a urologist, gynecologist or colorectal surgeon, depending on if the surgery is approached from the anus or the vagina. Surgical mesh, which had been used in the past, is no longer recommended for this condition. The FDA has recently approved the use of an implantable device that anchors the ligaments in the vaginal wall. In use since 2019, this is a fairly new approach to managing pelvic organ prolapse.
In deciding between a surgical repair and this novel approach, it is important to speak with your health care provider about the risks involved in each procedure. Once you have decided on a path forward, seek out a surgeon who specializes in pelvic floor conditions.
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